Current concepts in the surgical treatment of pediatric acute complicated rhinosinusitis

Introduction: Orbital and intracranial complications of acute rhinosinusitis in pediatric population are rare but must be suitably treated because they still represent life-threatening events. The aim of this study was to demonstrate that an early radiological diagnose associated to combined medical and surgical treatment can improve the management of these complications, decreasing their morbidity. Material and methods: We retrospectively reviewed all children (under 18 yearsold) treated for acute complicated rhinosinusitis in a period between 2002-2011 at the ENT Clinic of Varese Universitary Hospital (Italy). Patients were urgently admitted when symptoms and sings of acute rhinosinusitis suddenly worsened without benefit from empirical oral antibiotic therapy. All patient underwent at least one radiological investigation among CT and MR scan (in the last 5 years patients were all studied with both CT and MR). Treatment required the combination of broadspectrum intravenous antibiotics and endoscopic endonasal surgery eventually associated to external approaches in order to drain the inflammatory/infective site. Results: 22 patients were included in the present study and divided in 3 groups according to the type of complication. Group A included orbital complications which were observed in 17/22 cases (10 male, 7 female, with a mean age of 10,2 years). Among this group 10/17 cases were described as orbital cellulitis, whereas 7/17 cases as orbital abscesses. Group B included intracranial complications which were observed as subdural abscess in 2/22 cases (all male with a mean age of 13 years). Group C included 3/22 cases (2 male, 1 female, mean age 15,3 years) among which we could identify multiple orbital and intracranial complications. All 22 patients were treated with endoscopic endonasal surgery combined to medical therapy. In 8/22 cases (4 in Group A, 1 in Group B, 3 in Group C) it was necessary to associate also an external surgical approach (trans-facial approach in 5/8 cases, trans-cranial approach in 3/8 cases) in order to reach an effective control of the disease. No intra- and peri-operative complications were observed. Patients were then checked with regular endoscopic evaluation (eventually performed under general anesthesia according to their compliance) and at least one postoperative radiological examination (MR), with a mean follow up of 57,3 months. Conclusion: Complications of acute rhinosinusitis are rare but potentially serious entities. Early clinical recognition and institution of appropriate antibiotic therapy may lead to their improvement. Worsening of symptoms and signs should prompt imaging (better with MR) to determine the indication for a surgical drainage of the infection through an endoscopic endonasal approach eventually associated to a combined external approach in order to prevent its progression and evolution.